Aetna Anyone?

I need some advice. I have Aetna (PPO) and I cannot completely understand their requirements for approval. Basically I have to have 3 months of the following items. Nutritional advice, Exercise and Behavioral modifications. I can understand this and what I need to do for it but what I do not understand is the documentation they are asking for from me. They want me to meet with someone for the exercise and nutritional piece. I have met with the both of them but they said they do not need to see me again unless I have a question. Am I supposed to track everything I eat and when I work out to submit to them? I am kind of rambling here so I will stop. I think you all will have an idea of what kind of help I need.

Just for the heck of it, and to be thorough, keep a diary of your food intake and exercise. Then, make sure they physician you see, and it must be physician supervised, writes down each month your weight and any and all discussions regarding the diet progress, modifications etc...  Their notes must be very detailed.  If they simply chose to write a report after three months, they had better have the notes to back it up because chances are they'll be asked for them

Below is just "part" of the requires from Aetan and I believe to be an area they use to deny many people.  Note there are no requriements for weight loss or times you have to see the doctor or nutritionist.  But you do have to have the physicians initial assessment at the beginning of theis weight loss program and an assessment at the end.  Your nutritionist should also be alble to monitor your exercise requiement would is also vague.  Main thing is to get it in the medical record.  see the doctor monthly is my suggestion and be sure your doctor did the initial asssessment as I had appeal when mine did not do this.

1. Multidisciplinary surgical preparatory regimen: Proximate to the time of surgery, member must participate in organized multidisciplinary surgical preparatory regimen of at least three months duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions:
2. Consultation with a dietician or nutritionist; and
3. Reduced-calorie diet program supervised by dietician or nutritionist; and
4. Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and
5. Behavior modification program supervised by qualified professional; and

6. Documentation in the medical record of the member's participation in the multidisciplinary surgical preparatory regimen. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen.)

Hi there ... sounds like I am in the same boat as you ... got a question:  what if your BMI slips below 40, or slips below 35 if you have other medical conditions ... would Aetna still cover your surgery? ...

That's a great question and I would LOVE to know the answer.  I don't have the co-morbities they require for BMI's under 40.  I started my 3 month pre-op with a BMI of 43.  The problem is my surgeon wants me to lose another 10 pounds before surgery.  I can lose 6 more pounds, but a pound over that puts my BMI at 39.  I only have 4 more weeks of the pre-op diet, so I'm intentionally slowing my progress just to be safe.  The surgeon's office assures me it will be fine and that the determination will be based on my BMI from the beginning of the diet.  I'm not so confident because I haven't found one other person that went through this. 

I did the 3 month multidisciplinarian diet for Aetna through my doctor's office.  It entailed going to the doctor 4 times with 30 days in between.  The doctor had me do a food journal but never really looked at it.  I had to see a dietician, heart doctor, lung doctor and a shrink.  I also got records from the last 5 years from my pcp.  That involved a copy of one visit from the last 5  years that showed my weight.  The doctor submitted my stuff on April 19th and I got approved on April 26th.  Hope this helps.   From what I understand seeing the doctor for the 4 visits is the key.  And I have Aetna EPO.